Patient Application
If you do not have Health Insurance, and are looking for low cost testing supplies -
click here!
Please call us Toll-Free at 1(702) 649 5600 or submit the following information to us and we will contact you:
Before we can send your supplies and submit the claim to your insurer, we have to verify your information. Please e-mail the information requested below.
What kind of supplies do you need? What we can supply depends on what your insurance covers.
We understand that testing needs change, and you may need additional supplies prior to your scheduled quarterly shipment. Please feel free to let us know what items you are needing via this form.
Fields marked with * are mandatory
Meter
----------Select----------
Yes
No
Strips
----------Select----------
Yes
No
Lancets
----------Select----------
Yes
No
Insulin
----------Select----------
Yes
No
Syringes
----------Select----------
Yes
No
Shoes and inserts
----------Select----------
Yes
No
Erectile pumps
----------Select----------
Yes
No
We need following information to get started :
I am submitting this form for
----------Select----------
Myself
Family Member
Friend
Name of submitter
(If different from patient)
Name of patient *
Sex *
----------Select----------
Male
Female
Mailing Address
City *
State *
ZIP *
Day-time Phone Number
Primary Insurance
(Sorry, No HMO's)
----------Select----------
Medicare
Major Medical
Champus
HMO
No Insurance
Name of Insurance Company
Is the patient the insured party?
----------Select----------
Yes
No
If NO, Name of Insured
Secondary Insurance?
----------Select----------
Yes
No
Physician's Name
Street Address
City
State
Zip
Phone Number
Insulin or Pill dependency
----------Select----------
Insulin
Pill
How many tests per day
Your E-mail address *
FAX (If applicable)
Please contact me as soon as possible regarding this matter.
Enter your comments in the space provided below :
E-mail us if you want additional subjects to chat about.
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